Sexual Safety and Women issues in Acute Mental Health Care

Chris Holley, West Midlands NIMHE Gender Equality and Women's Mental Health Programme Lead
Lynne Johnson, Women's Services Development Co-ordinator, Birmingham and Solihull Mental Health Foundation Trust

Mainstreaming Gender and Women's Mental Health, DH 2003

Although this was in the context of the development of women's mental health services, DH policy makes it clear that sexual safety should be a routine consideration for both women and men.

Gender Equality Duty

From April 2007 the Gender Equality Duty required public bodies to promote equality between women and men, by having policies and procedures in place which take account of their different needs. The Equalities Bill, legislation planned for 2009, will establish a single Equality Duty requirement incorporating all equalities.

NPSA

In 2006, The NPSA (National Patient Safety Agency) in the report: "With Safety in Mind: Mental Health Services and Service user Safety" referred to the high number of
sexually related incidents reported within healthcare settings, confirming that sexual safety is of national significant concern, particularly since it is likely that there is underreporting.

New Ways of Working

Aims to ensure that services provide high quality, person-centred, effective services by creating ‘Capable Teams' who work with the service user as a whole person, not a set of symptoms."

So ... what is sexual safety and why did we do this?

Service users and staff have the right to privacy, dignity and the provision of a safe environment where they are free from sexual harassment and exploitation, irrespective of gender; ethnicity; sexual orientation; religion/belief; age; and disability.
Sexual aggression and violence in in-patient settings is a serious, not infrequent, yet often difficult area for staff do deal with.
The ward should be a safe place for all, protecting people from receiving or perpetrating behaviour of a sexual nature.

Professional boundaries

The Council for Healthcare Regulatory Excellence defines a breach of sexual boundaries as a range of behaviours which may include rape or sexual assault; sexual relationships; and other "sexually motivated actions towards patients such as sexual humour or inappropriate comments".

"Breaches of sexual boundaries by healthcare professionals are unacceptable because:

They can cause significant enduring harm to patients
They damage trust - the patients trust in the healthcare professional and the public trust in healthcare professionals in general
They impair professional judgement. Sexual or inappropriate involvement with a patient may influence a healthcare professional's decisions about care and treatment to the detriment of the patient" (Council for Healthcare Regulatory Excellence, 2008)

Getting the balance right

"More than in other medical settings, the psychological relationship between staff and the service user is an essential part of the treatment in psychiatry." (Royal College of Psychiatrists 2007)
Therapeutic caring relationships between staff and service users must focus solely on the health and social care needs of the service user and not to build personal or social contacts for staff. The NMC guidance states that moving the focus of care away from the service users' needs - towards meeting the staff's needs - is an unacceptable abuse of power. (NMC March, 2006)

Intimate relationships between service users

We have a duty of care
Recognise emotional vulnerability
Staff responsibility to keep s/users safe
Consider others potentially affected by their actions (carers, children, partners)

Capacity and Consent

In the event of alleged sexual assault

If the service user is willing for the police to be informed ... the process.
Protecting forensic evidence and Early Evidence Kits
If the service user does not want to report the matter to the police ...retaining evidence, with permission.
Documentation.

Sexual Health Issues

Links should be developed with local sexual health services to enable service users to access expert support and advice whilst in the ward environment. Alternatively, service users are able to access local contraception and sexual health services. The clinics can serve as educators in safe sex, sexual counselling and in HIV or Aids related issues. Sex education may be considered as part of a comprehensive treatment package within the Care Programme Approach.

Sexual Abuse Issues

CPA guidance states that:"Questions should be asked by suitably trained staff at assessment about the experience of physical, sexual or emotional abuse at any time in the service user's life. The response, with brief details,
should be recorded in case records/care plans.
If the specific question is not asked, the reason(s) for not doing so should be recorded."

Refocusing the Care Programme Approach, Policy and Positive Practice Guidance, Section 4, March 2008

Cultural and Ethnic Minority Issues

Female Genital Mutilation

FGM was described in 2000, by the World Health Organisation (WHO) as the "procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons". Different communities use different types of FGM.

Pornography

Definition: "The explicit depiction or exhibition of sexual activity in literature, films or photography that is intended to stimulate erotic, rather than aesthetic or emotional feelings." (Media Awareness Network, 2008)
Staff should be aware of the potential impact that pornographic or sexually explicit material can have upon issues pertaining to sexual safety.
Consider the use of any media, for example: DVD; video; cassette; CD, which is potentially offensive to any service users or staff who may come into contact with it